Crash of a De Havilland DHC-3 Otter in Long Haul Lake: 1 killed

Date & Time: Jun 25, 1999 at 1320 LT
Type of aircraft:
Operator:
Registration:
C-FIFP
Flight Phase:
Flight Type:
Survivors:
Yes
MSN:
73
YOM:
1955
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
1
Aircraft flight hours:
23960
Circumstances:
The Blue Water Aviation Services seaplane departed from Long Haul Lake, Manitoba, with a pilot and an aviation maintenance engineer on board. Shortly after take-off, at 1320 central daylight savings time, the aircraft's engine abruptly lost power. The pilot's attempts to restart the engine were unsuccessful, and the aircraft descended into a stand of trees and struck the ground. The engineer suffered fatal injuries, and the pilot was seriously injured. The aircraft was destroyed by impact forces.
Probable cause:
Findings as to Causes and Contributing Factors:
1. The most likely accident scenario during the second take-off is that water contamination migrated from the centre fuel tank to the engine, resulting in a loss of engine power.
2. The engine stopped at a point from which there was insufficient time for the engine to restart, nor from which a safe landing could be made.
3. Indications of water contamination were found in the fuel system after the occurrence; however, the source(s) of the water contamination could not be identified.
Other Findings:
1. Examination of the aircraft and testing of the engine and components did not identify any pre-occurrence structural, mechanical, or electrical defects or malfunctions that would have
contributed to this occurrence.
2. The post-crash fire in the carburettor most likely resulted from uncontaminated fuel brought forward by the windmilling engine and the pilot's efforts to clear contamination from the fuel
system.
3. The pilot's use of his shoulder harness likely prevented more serious injuries during the impact sequence.
4. The engineer's injuries likely would have been less severe had he been using both his seat belt and shoulder harness.
5. The pilot was certified and qualified for the flight.
6. The aircraft's weight and centre of gravity were within approved limits.
7. The aircraft's records indicated that the aircraft had been certified and maintained in accordance with existing regulations.
8. The aircraft's engine power loss during the first attempted take-off was likely due to water contamination in the fuel.
Final Report:

Crash of a Cessna 421C Golden Eagle III in Concord: 4 killed

Date & Time: Jun 14, 1999 at 1257 LT
Registration:
N421LL
Flight Phase:
Survivors:
No
Schedule:
Concord – Anderson
MSN:
421C-0305
YOM:
1977
Crew on board:
1
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
4
Captain / Total flying hours:
7500
Captain / Total hours on type:
3000.00
Aircraft flight hours:
5145
Circumstances:
An aircraft mechanic stated one of the airplanes engines was making an unusual noise during takeoff. An Air Traffic Controller stated the flight used about 4,500 feet of runway before lifting off. About 1 minute after being cleared for takeoff, the pilot reported 'were coming around were losing a right engine'. The controller and a witness observed the airplane level off, sway to the left and right, and then descend. The pilot reported he was not going to make it. The airplane was lost from sight behind trees. Post crash examination of the airplane structure, flight controls, engines, and propellers showed no evidence of pre-crash failure or malfunction that would have prevented operation. The landing gear and wing flaps were found retracted. The left and right propellers were found in the low blade angle position and had similar damage. An NTSB sound study of ATC communications showed that at the time the pilot reported they were not going to make it, a propeller signature showed 1,297 rpm and another propeller signature of 2,160 rpm. The engine inoperative procedure contained in the Pilot Operating Handbook for the Cessna 421C, calls for the throttle on the inoperative engine to be closed, the mixture placed in idle cut-off, and the propeller feathered. The Pilot Operating Handbook also showed the airplane would normally use 2,000 feet of runway for takeoff under the accident conditions.
Probable cause:
The failure of the pilot to shutdown the right engine and feather the propeller after a reported loss of power in the engine shortly after takeoff resulting in the airplane descending, colliding with trees and then the ground.
Final Report:

Crash of a Beechcraft A100 King Air in Thunder Bay

Date & Time: Jun 14, 1999 at 1038 LT
Type of aircraft:
Operator:
Registration:
C-GASW
Flight Phase:
Survivors:
Yes
Schedule:
Thunder Bay – Red Lake
MSN:
B-108
YOM:
1972
Flight number:
THU103
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The Thunder Airlines Limited Beech A100 King Air aircraft, serial number B108, took off at 1034 eastern daylight saving time (EDT) on a charter flight from Thunder Bay, Ontario, for Red Lake, Ontario, with two pilots and three passengers on board. After getting airborne, the aircraft pitched up to approximately 70 degrees, reaching a height estimated to be between 500 and 700 feet above ground level. It then rolled to the left, pitched steeply nose-down, and descended to the ground within the confines of the airport. The aircraft contacted the soft, level ground in a relatively level attitude and covered a distance of about 500 feet before coming to rest in a wooded area immediately beyond an elevated railroad bed and track. The cabin remained intact during the crash sequence, and all occupants escaped without any injuries. The aircraft was damaged beyond repair. An ensuing fuel-fed fire was rapidly extinguished by airport emergency response services (ERS)
personnel.
Probable cause:
The flight crew lost pitch control of the aircraft on take-off when the stabilizer trim actuators became disconnected because they had not been properly reinstalled by the AME during maintenance work conducted before the flight. The crew chief responsible for the inspection did not ensure correct assembly of the stabilizer trim actuators, which contributed to the accident.
Final Report:

Crash of a Piper PA-31-350 Navajo Chieftain in Tanana: 1 killed

Date & Time: Jun 11, 1999 at 0723 LT
Operator:
Registration:
N41078
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Fairbanks – Tanana – Galena
MSN:
31-8352017
YOM:
1983
Flight number:
LFS1604
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
3227
Captain / Total hours on type:
861.00
Aircraft flight hours:
15229
Circumstances:
A twin-engine airplane on a scheduled passenger/cargo flight, departed a rural airport located along the north shore of the Yukon River with only the pilot aboard. The airplane appeared to depart normally, but remained low, flying over the river, about 200 feet above the ground. About five minutes after departure, the pilot contacted a local weather observation facility on the common traffic advisory frequency (CTAF), and reported he was having a problem with the airplane, stating he may have to ditch. He did not describe the nature of the problem. The pilot then said he was clipping trees, and was attempting to return to the runway. The airplane collided with several trees located on a gravel bar in the Yukon River, separating the outboard end of the left wing. The airplane then collided with the river and sank, about 1.5 miles south of the airport. A fast river current, and silty water conditions hampered recovery efforts, but the left wing, the left engine, and the fuselage were recovered from the river. The left engine propeller appeared to be feathered. The right wing and the right engine were not recovered. Postaccident examination of the left engine disclosed no evidence that it was producing power upon impact, or any evidence of any preimpact mechanical malfunction. Inspection of the airframe disclosed no evidence of any preimpact mechanical malfunction.
Probable cause:
The exact cause of the accident could not be determined.
Final Report:

Crash of a Lockheed C-130 Hercules in Kukës

Date & Time: Jun 11, 1999
Type of aircraft:
Operator:
Registration:
XV298
Flight Phase:
Flight Type:
Survivors:
Yes
MSN:
4264
YOM:
1968
Location:
Country:
Region:
Crew on board:
6
Crew fatalities:
Pax on board:
9
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
On the night of 11 June 1999, RAF Hercules XV298 was tasked to collect personnel and equipment from Kukes airstrip, Albania. The aircraft flew from Italy and landed on the unlit airstrip using normal Night Vision Goggle (NVG) procedures. The crew had been briefed that there would be sufficient runway remaining from the pickup point to the end of the airstrip. The crew were unable to see the end of the airstrip as artificial lighting in the near distance interfered with their night vision goggles. After loading personnel and equipment it began its takeoff run along the remaining available runway, but soon hit a fence and several other ground obstacles. XV298 slowed then veered to the right, suffering severe damage to its right wing before stopping. Fuel leakage from the damaged wing ignited and the subsequent fire destroyed much of the aircraft.
Probable cause:
The Board quickly discounted aircraft performance or serviceability as factors in the accident, concluding that the take-off distance was insufficient for the aircraft to get airborne safely . This was partly due to anomalies in the operating instructions for tactical landing zone operations which were contained in three separate documents - one used by the aircrew, one for personnel training, and the other used by the airstrip marking party. Consequently each party had different expectations as to what procedure would be followed, which in turn led to the airstrip markings having been laid out differently to those briefed to the aircrew . Further, the Board established that the airstrip data used to plan the sortie was significantly different from the actual airstrip dimensions ; and also concluded that reduced night vision goggle performance contributed to the accident. The Board of Inquiry concluded that the accident was caused because the take-off distance was insufficient for the aircraft to get airborne safely.

Crash of a Piper PA-60 Aerostar (Ted Smith 600) in Montgomery

Date & Time: May 29, 1999 at 1724 LT
Registration:
N601JS
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Montgomery – Columbus
MSN:
60-0553-179
YOM:
1978
Crew on board:
1
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
5000
Captain / Total hours on type:
1000.00
Aircraft flight hours:
2322
Circumstances:
During the takeoff roll and initial climb both engines were producing normal power. As the airplane climbed through 150 feet, the left engine lost power. The pilot reported that he feathered the left propeller. He further stated that following the securing of the left engine, the right engine began to 'power down.' The pilot reported that he was unable to maintain a climb attitude and was forced to land on the airport in a grassy area. The subsequent examination of the cockpit disclosed that the left engine throttle was in the full forward position, and the right throttle lever was in the mid-range position. Both propeller levers were found full forward. The left engine mixture lever was in the full forward position, and the right mixture lever full aft, or lean, position. The functional check of both engines was conducted. Initially the left engine would not start, but after troubleshooting the fuel system, the left fuel boost pump was determined to have been defective. The 'loss of engine power after liftoff' checklist requires that the pilot identify the inoperative engine and to feather the propeller for the inoperative engine.
Probable cause:
The pilot's inadvertent shutdown of the wrong engine that resulted in the total loss of engine power. A factor was the loss of engine power due to fuel starvation when the left fuel boost pump failed.
Final Report:

Crash of a Let L-410UVP-E9 in Olkiombo: 2 killed

Date & Time: May 29, 1999 at 1400 LT
Type of aircraft:
Registration:
5Y-LET
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Olkiombo - Mara Shika
MSN:
91 26 20
YOM:
1991
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Circumstances:
Shortly after takeoff from Olkiombo Airstrip, while in initial climb, the aircraft stalled and crashed past the runway end. The aircraft was destroyed and both pilots were killed. They were completing a positioning flight to the Mara Shika Airfield, in the Maasai Mara National Reserve, to pick up passengers.
Probable cause:
Loss of control during initial climb after the aircraft stalled because the crew forgot to select flaps in an appropriate angle for takeoff.

Crash of a Mitsubishi MU-2B-40 Solitaire in Parry Sound: 2 killed

Date & Time: May 24, 1999 at 2130 LT
Type of aircraft:
Registration:
N701K
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Parry Sound – Toronto
MSN:
410
YOM:
1979
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
5500
Captain / Total hours on type:
400.00
Circumstances:
With one pilot and one passenger, the Mitsubishi MU-2B-40 Solitaire aircraft, serial number 410 S.A., departed on a night instrument flight rules flight from Parry Sound / Georgian Bay Airport, Ontario, destined for Toronto / Lester B. Pearson International Airport. Prior to departure, the pilot received his instrument flight rules clearance via telephone from the Sault Ste. Marie flight service station with a clearance valid time of 2118 eastern daylight time from Toronto Area Control Centre and a clearance cancel time of 2135. When the pilot did not establish communications with Toronto Area Control Centre within the clearance valid time, the Area Control Centre supervisor commenced a communication search. At 2151, he confirmed with Parry Sound / Georgian Bay Airport personnel that the aircraft had departed 10 to 15 minutes earlier. The aircraft was assumed missing and the Rescue Coordination Centre in Trenton, Ontario, was notified. Search and rescue was dispatched and three days later the aircraft wreckage was located one nautical mile west of the airport. Both of the aircraft occupants were fatally injured. The aircraft disintegrated as it cut a 306-foot swath through the poplar forest. The accident occurred at night in instrument meteorological conditions.
Probable cause:
Findings as to Causes and Contributing Factors:
1. The accident flight was conducted at night in IMC, and the pilot, whose private pilot licence was not endorsed with an instrument rating, was not certified for the IFR flight.
2. The pilot may have been subjected to somatogravic illusion and allowed the aircraft to descend into terrain after a night take-off in IMC.
3. The pilot did not completely report his medical conditions to the civil aviation medical examiner.
Other Findings
1. The pilot was not certified to fly this model of aircraft as his private pilot licence was not endorsed with the appropriate high-performance aircraft rating.
2. The pilot conducted a downwind take-off.
3. While the aircraft was turning left for the on-course track, the aircraft flaps were retracting.
4. The aircraft struck trees while in a shallow descent. The integrity of the aircraft was compromised as it rolled inverted and entered the impact zone at high speed.
5. The aircraft engine teardown examination revealed no pre-impact failures of any component parts or accessories in either the left or right engine that would have precluded normal engine operation.
6. The propeller teardown examination revealed that both propellers were in a normal operating range and were rotating with power at the time of impact.
7. The ELT did not function due to the impact damage sustained by its various components.
Final Report:

Crash of a Cessna 421B Golden Eagle II off Stauning

Date & Time: May 21, 1999 at 0002 LT
Operator:
Registration:
OY-BIM
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Stauning - Manchester
MSN:
421B-0878
YOM:
1974
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
3706
Captain / Total hours on type:
361.00
Copilot / Total flying hours:
650
Copilot / Total hours on type:
54
Aircraft flight hours:
5518
Circumstances:
The twin engine aircraft departed Stauning Airport at 0000LT on a cargo flight to Manchester with two pilots on board. Shortly after takeoff from runway 27, while in initial climb by night, the crew declared an emergency after the main cabin door opened. The captain reduced both engines power and the aircraft crash landed on the Klægbanke, less than 4 km from the airport. Both pilots were rescued an hour later (they were uninjured) and the aircraft was damaged beyond repair.
Probable cause:
The main cabin door opened during initial climb because the crew failed to ensure it was properly closed. Investigations reported that the door locking mechanism was not properly adjusted and that the crew did not identify the abnormal situation. The following factors were identified:
- The captain immediately reduced power on both engines when the door opened,
- The captain was not properly trained,
- The operator did not ensure that the crew was qualified and trained to perform this type of flight,
- The crew failed to follow the pre departure checklist,
- The crew's attention was focused on the door that opened at a critical moment of the flight and failed to continue the flight and monitor the various instruments.
Final Report:

Crash of an Antonov AN-26 near Luzamba

Date & Time: May 12, 1999
Type of aircraft:
Registration:
D2-FBN
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Luzamba - Luanda
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
After takeoff from Luzamba Airport, while on a cargo flight to Luanda on behalf of the Angolan operator Avita Serviços Aéreos, the aircraft was hit by a surface-to-air missile that struck an engine. The crew reduced his altitude and was able to make an emergency landing in an open field some 30 km from Luzamba. All five occupants evacuated safely but were captured by UNITA rebels.
Probable cause:
Shut down by a UNITA surface-to-air missile.